Safer Healthcare Now! Ventilator Acquired Pneumonia

1. Safer Healthcare Now! Ventilator Acquired Pneumonia Presented by Amanda Thompson, Safer Healthcare Now Facilitator April 12, 2007

2. Safer Healthcare Now! Background • Largest patient safety initiative in Canadian history • Adopted from IHI • Over 600 teams registered across Canada • Goal to improve health care delivery through 6 initiatives

3. Safer Healthcare Now! Initiatives • Acute Myocardial Infarction (AMI) • Ventilator Associated Pneumonia (VAP) • Central Line Associated Infection (CLI) • Prevention of adverse drug events through Medication Reconciliation (Med. Rec) • Prevention of Surgical Site Infection (SSI) • Rapid Response Teams (RRT)

4. VAP - Ventilator Associated Pneumonia DEFINITION – “An airway infection developed more than 48 hours after a patient was intubated” • Leading cause of death • Increased ICU stay • Increased hospital stay • Increased costs

5. Signs & Symptoms of VAP New, worsening or persistent infiltrate on CXR compatible with pneumonia and 2 of the following: • WBC > 11 or neutropenia • Temp > 38 • Change in sputum • Pathogen isolated form sputum in last 48 hrs • Increasing O2 requirements for > 2 hrs Note: Presence of crackles or bronchial breathing, and confusion in older pt’s is a good indicator of pneumonia.

6. Goals • Decrease VAP by 50% in one year

7. VAP Bundle • HOB increased 30 – 45° • Daily sedation vacation with SBT • OG vs. NG • EVAC tubes

8. VAP Bundle cont’d “Teams that have unfailingly accomplishedevery bundle element, on every patient, every time ,have gone months without a single case of pneumonia associated with the ventilator”.

9. Initiation of VAP Required: • Closed systems • Good mouth care • Oral decontamination • Proper hand washing

10. Head of Bed (HOB) • Constant HOB elevation • Decreased VAP by 78% • Decreased risk of aspiration • Pt’s in supine position have lower spontaneous tidal volumes on pressure support • Minimize atelectasis

11. Sedation Vacation with SBT • Stopping sedation at regular times every day. For example: morning assessment • RT to do a SBT • Decreases MV time from 7.3 days to 4.9 days • Weaning becomes easier • Use Riker Scale

12. Oral vs. Nasal • Oral endotracheal as well as oral gastric • Reduces frequency of nosocomial sinusitis from 73% to 34% • Nosocomial infections is a leading cause of death

13. EVAC Tubes • Removes pooled secretions from subglottic region • Reduces VAP from 39.6 to 19.9

14. Additional Components of Quality Ventilator Care • Peptic Ulcer Disease (PUD) prophylaxis • Decreased PH of gastric contents, may protect against pulmonary inflammatory response to aspiration • Decreased hospital stay • Deep Venous Thrombosis (DVT) prophylaxis • Decreased complications = Decreased Hospital Stay • Early Nutrition • Shown to decrease nosocomial infections

15. VAP Checklist HOB: HI = Hemodynamic Instability SP = Spinal Precautions PR = Undergoing Procedure AG= Agitated NR = No Reason OG: OT= Oral Trauma SU = Post Oral Surgery TR = Trach Insitue NGS = NG Sutured PE= Planned Extubation SBT: CNM = Criteria Not Met EVAC: NA = Not Available SI = ETT size > 6.0 TR = Trached *Adapted from a tool created by Dominical Hospital (Santa Cruz, CA) March 20, 2007

16. VAP Improvement • Since implementing 2 of the 4 elements, VAP has decreased. • With continued use and implementation of all bundle elements, we can and will decrease VAP dramatically.

18. Questions?

19. Contact Information Amanda Thompson 709-292-2647 athompson@cwhc.nl.ca www.saferhealthcarenow.ca

20. Thank You!